I enjoy what I do. For some weird reason, I like to read and do my best to interpret the Medicare regulations. I hope my efforts make it easier for hospitals to receive the appropriate reimbursement for the healthcare services they provide by helping them to follow Medicare’s documentation, coding and billing requirements. But unfortunately, the news I share is not always the best news or even fun. So before I get into the “not so fun” part of this article, I want to acknowledge National Radiologic Technology Week.

As in many areas of healthcare, radiology includes many different types of services, such as plain x-rays, computed tomography (CT), magnetic imaging resonance (MRI), ultrasound, nuclear medicine, interventional radiology, radiation oncology, and others. Radiologic technologists provide a valuable contribution to healthcare. How many times over the past year have you, your family or friends received radiologic services? How would your care have been affected without this technology? Within my own circle of family and friends – an x-ray for a broken wrist, annual mammogram, Dexa scan, MRI for spinal stenosis, and CT to rule out a pulmonary embolism. So thanks to all our radiology friends!

A few weeks ago an article reviewed some of the National Correct Coding Initiative (NCCI) guidance for respiratory services for their recognition week. Continuing that theme for National Radiology Week, let’s look at some of the NCCI instructions that apply to Medicare coding and billing for radiology services.

A recent NCCI edit (July 2014) bundled spinal myelography procedures (72240-72270) into procedures for CT neck, chest and lumbar studies (72125-72133). The code pairs may be reported together with the appropriate modifier when warranted. If both tests are medically necessary, distinctly ordered, and there is a separate interpretation for each procedure, then it is appropriate to append modifier 59 to the CT of the spine with contrast code to identify that it is a separate and distinct procedure. (CPT Assistant September 2014)

The following are selected excerpts from the Radiology chapter of the NCCI manual. For complete information regarding these topics and other radiologic issues, please see Chapter IX of the NCCI Policy Manual found in the downloads section of the Medicare NCCI Website.

• CPT code descriptors that specify a minimum number of views include additional views if there is no more comprehensive code specifically including the additional views.
• CPT Manual instructions state that in the presence of a clinical history suggesting urinary tract pathology complete ultrasound evaluation of the kidneys and urinary bladder constitutes a complete retroperitoneal ultrasound study (CPT code 76770). A limited retroperitoneal ultrasound (CPT code 76775) plus limited pelvic ultrasound (CPT code 76857) should not be reported in lieu of the complete retroperitoneal ultrasound (CPT code 76770).
• When a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax. Similarly when an emergency endotracheal intubation procedure (CPT code 31500), chest tube insertion procedure (e.g., CPT codes 32550, 32551, 32554, 32555), or insertion of a central flow directed catheter procedure (e.g., Swan Ganz)(CPT code 93503) is performed, a chest radiologic examination is usually performed to confirm the location and proper positioning of the tube or catheter. The chest radiologic examination is integral to the procedures, and a chest radiologic examination (e.g., CPT codes 71010, 71020) should not be reported separately.
• CPT code 75635 describes computed tomographic angiography of the abdominal aorta and bilateral iliofemoral lower extremity runoff. This code includes the services described by CPT codes 73706 (computed tomographic angiography, lower extremity...) and 74175 (computed tomographic angiography, abdomen...). CPT codes 73706 and 74175 should not be reported with CPT code 75635 for the same patient encounter. CPT code 73706 plus CPT code 74175 should not be reported in lieu of CPT code 75635.
• Diagnostic angiography (arteriogram/venogram) performed on the same date of service by the same provider as a percutaneous intravascular interventional procedure should be reported with modifier 59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 59.
• Fluoroscopy reported as CPT codes 76000 or 76001 is integral to many procedures including, but not limited, to most spinal, endoscopic, and injection procedures and should not be reported separately. For some of these procedures, there are separate fluoroscopic guidance codes which may be reported separately.
• Computed tomography (CT) and computed tomographic angiography (CTA) procedures for the same anatomic location may be reported together in limited circumstances. If a single technical study is performed which is utilized to generate images for separate CT and CTA reports, only one procedure, either the CT or CTA, for the anatomic region may be reported. Both a CT and CTA may be reported for the same anatomic region if they are performed at separate patient encounters or if two separate and distinct technical studies, one for the CT and one for the CTA, are performed at the same patient encounter. The medical necessity for the latter situation is uncommon.
• If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with mammographic guidance (e.g., 19281,19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.
• CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.
• The code descriptor for CPT code 77417 states “Therapeutic radiology port film(s)”. The MUE value for this code is one (1) since it includes all port films.
• An MRI study of the brain (CPT codes 70551-70553) and MRI study of the orbit (CPT codes 70540-70543) are separately reportable only if they are both medically reasonable and necessary and are performed as distinct studies. An MRI of the orbit is not separately reportable with an MRI of the brain if an incidental abnormality of the orbit is identified during an MRI of the brain since only one MRI study is performed.

There are more rules on coding and reporting radiology services on a claim than there are slices of a CT scan. And that is not so fun!

Coding Kwashiorkor has been and continues to be a hot topic for contractors (e.g., Recovery Auditors and the Office of Inspector General (OIG)). In fact, auditing claims including a diagnosis of Kwashiorkor to determine if the record adequately supports the diagnosis was a new scope of work in the FY 2014 OIG Work Plan and is a continued scope of work in the FY 2015 OIG Work Plan. In the Work Plan the OIG indicates that “a diagnosis of Kwashiorkor on a claim substantially increases the hospitals’ reimbursement from Medicare.”

What is Kwashiorkor?

According to the National Institutes of Health, “Kwashiorkor is a form of malnutrition that occurs when there is not enough protein in the diet. Kwashiorkor is most common in areas where there is:

• Famine
• Limited food supply
• Low levels of education (when people do not understand how to eat a proper diet)
• Dates of service of records reviewed ranged from 2010 – 2013 with most records being prior to 2013.

This disease is more common in very poor countries. It often occurs during a drought or other natural disaster, or during political unrest.”

“Kwashiorkor is very rare in children in the United States. There are only isolated cases. However, one government estimate suggests that as many as 50% of elderly people in nursing homes in the United States do not get enough protein in their diet.

When Kwashiorkor does occur in the United States, it is usually a sign of child abuse and severe neglect.”

Kwashiorkor and the OIG Work Plan

In fulfillment of the Work Plan, the OIG has completed several hospital audits that found that hospitals had incorrectly billed Medicare inpatient claims with Kwashiorkor.

In the audit reports, the OIG indicates that Kwashiorkor generally affects children and the Medicare program is primarily provided to people age 65 or older. Yet, “for calendar years (CYs) 2010 and 2011, Medicare paid hospitals $711 million for claims that included a diagnosis for Kwashiorkor. Therefore, we are conducting a series of reviews of hospitals with claims that include this diagnosis code.”

Key Takeaways from 2014 OIG Reports:

• Consistent in the findings for all of the hospitals was that almost all claims reviewed did not comply with Medicare requirements for billing Kwashiorkor in that they used code 260 but should have used codes for other forms of malnutrition. In several instances removing code 260 did not result in a DRG change. When it did result in a DRG change it resulted in overpayments being made to the hospital.
• The combined overpayment by Medicare was $2,074,341. This is staggering when you consider that this amount is overpayment for one single secondary diagnosis code at only twelve hospitals.
• The reasons for coding errors sited by the hospitals included:
• Lack of clarity in the coding guidelines,
• Issues with the medical coding software program used to code the diagnosis; and
• Incorrect guidance from a third party consultant.

What Guidance is Available to Hospitals?

To answer the “lack of clarity in coding guidelines” for coding Kwashiorkor here are two resources that hospitals can look to for malnutrition coding guidance.

Coding Clinic

Volume 3, Issue 1 , page 3 of the October 2012 Medicare Quarterly Compliance Newsletter, provides an example of a Recovery Auditor findings where Kwashiorkor had been coded as a secondary major comorbidity incorrectly and refers the reader to Coding Clinic, Third Quarter 2009.

Specifically, Coding Clinic, Third Quarter 2009, p. 6 advises hospitals to only code 263.0 for moderate protein malnutrition as this category also includes protein-calorie malnutrition. Coding Clinic further advises that unless the physician specifically documents Kwashiorkor Code 260 should not be used.

Consensus Statement

The American Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN) published a Consensus Statement in the May 2012 Journal of the Academy of Nutrition and Dietetics.

This article acknowledges that “the diagnosis of malnutrition in a patient is an undeniably complicating condition that in many cases significantly increased resource utilization in the acute care setting beyond that experienced by the patient in nutritional health.”

While hospitals have historically looked to serum albumin and prealbumin levels as an indicator of malnutrition, the Academy’s Evidence Analysis Library (EAL) analysis found that “acute-phase proteins do not consistently or predictably change with weight loss, calorie restriction, or nitrogen balance. They appear to better reflect severity of the inflammatory response rather than poor nutritional status.”

This article also notes that “CMS has also questioned the use of acute-phase serum proteins as primary diagnostic criteria for malnutrition since studies increasingly suggest limited correlation of these proteins with nutritional status.”

The Academy and Aspen state that two of the following six characteristics should be identified in a patient when diagnosing malnutrition:

• Weight loss;
• Loss of muscle mass;
• Loss of subcutaneous fat;
• Localized or generalized fluid accumulation that sometimes mask weight loss; and
• Diminished functional status as measure by hand grip strength
• Insufficient energy intake;

It is advised that these characteristics be assessed at the time of the hospital admission and “at frequent intervals throughout the patient’s stay in an acute, chronic, or transitional care setting.”

The article goes on to site a study by Fry and colleagues that “showed that preexisting “malnutrition and/or weight loss” was a positive predictive variable for all eight major surgery-associated “never events” (inexcusable outcomes in a health care setting.”

Assessment, diagnosis and treatment of malnutrition are critical for the wellbeing of our patients. Equally important is identifying the characteristics that need to be assessed in formulating the correct type of malnutrition (e.g. moderate or severe) diagnosis. This article contains a table with detailed clinical criteria to assist in determining the severity levels of malnutrition and I strongly encourage you to read this article.

It pains me to admit that my nursing school days are now decades in the past. With that said, there are still key mnemonics that helped me survive the information overload. One particular example is the five stages of coping or D.A.B.D.A. (Denial, Anger, Bargaining, Depression and Acceptance). As I began writing this article it struck me that the stages of coping must be similar to the stages hospital Appeals Coordinators are dealing with in regards to Medicare’s five stages of appeals.

Level 1: Redetermination by a Medicare Administrative Contractor (MAC) a.k.a. Denial

Once a claim has been denied by your MAC, and on internal review you can’t believe that the hospitalization was denied you would request a Redetermination. It is at this level that the MAC will perform a document review of the initial claim determination.

Level 2: Reconsideration a.k.a. Anger

At this point you can become both frustrated and irritated that the same MAC has denied what you believe to be a medically necessary hospitalization twice so you press on to the Reconsideration level. At this level a Quality Independent Contractor (QIC) will perform a document review of the Redetermination and a hospital may still submit any evidence not previously present to support the medical necessity for the admission.  

Level 3: Administrative Law Judge (ALJ) Hearing a.k.a. Bargaining

It is at this level that we will spend the most time on today.

This past July, Nancy J. Griswold, the Chief Administrative Law Judge for the Office of Medicare Hearings and Appeals (OMHA) made a statement before the United States House Committee on Oversight & Government Reform. Ms. Griswold reported that the OMHA adjudication capacity is approximately 72,000 appeals a year. However, “weekly appeal levels have ranged between 10,000 and 16,000 throughout FY 2014. As a result, OMHA had over 800,000 appeals pending on July 1, 2014. At current receipt and adjudication capacity levels, OMHA’s Central Operations, which is the focal point for all incoming appeals, is receiving one year’s worth of appeals every four to six weeks.”

So, what exactly does this translate into at the individual hospital level? According to the OMHA web page, “the average processing time for appeals decided in fiscal year 2014 is 414.8 days.” However, as you continue to look through their web page, by September of this year the average appeals processing time was 514.5 days.

Added to this delay is the recent release of Transmittal 543 where CMS asserts that “significant time and effort is spent by CMS and its contractors to ensure that review staff are making quality decisions. It is important for contractors to support and defend their medical review decisions throughout the appeals process, including at Administrative Law Judge (ALJ) hearings.” In line with this assertion this Transmittal instructs Medicare Administrative Contractors (MACs) “to support their medical review decisions through the ALJ level of appeal.”

Key Guidance in Transmittal 543 Effective October 27, 2014:

• For claim determinations made by the MAC they “shall assign a physician to participate or take party status “ at ALJ hearings,
• The Physician “is generally the primary individual overseeing and/or taking party/participant status, a contractor may elect to have an attorney or clinician take party or participant status, or another qualified individual if approved by the COR.”
• MACs shall determine a process to identify cases that they will participate in at the ALJ level of appeal. “Factors to be examined should include, but not be limited to policy implications, dollars at issue, source of the denial, program integrity matters, and the extent to which a particular issue is, or has been, a recurring issue at the ALJ level of appeal.”
• “MACs shall coordinate with the QIC to ensure timely notification of all ALJ hearings.”
• “For extrapolation cases, the MAC shall be prepared to discuss the background on how the provider/supplier was selected for review, results of the sample case adjudications, as well as matters related to the extrapolation process.”

Why include the MACs now? In part, this could be in response to the 2012 OIG report where the OIG found that improvements are needed at the ALJ Medicare Appeals level, that in FY 2010 the ALJ reversed the decisions of the QICs in favor of the appellants 56 percent of the time, and one recommendation made in this report was to “continue to increase CMS participation in the ALJ appeals.”

This is where the bargaining comes into play. As a hospital, should we stay the course with the appeal even though it may be more than a year before it goes before the ALJ, or should we consider one of the options currently being offered by CMS (Statistical Sampling Initiative, Settlement Conference Facilitation Pilot, or the Medicare Appeals Settlement Offer)?

Level 4: Medicare Appeals Council Review a.k.a. Depression

CMS instructs that “if you disagree with the ALJ decision, or you wish to escalate your appeal because the ALJ ruling timeframe passed, you may request a Medicare Appeals Council review.”

It is also at this level that it would be easy for depression to set in due to the fact that even though you continue to believe in the medical necessity of the case you are appealing you also realize that by now you have spent countless hours and more than likely at least two years or more championing your appeal.

Level 5: Judicial Review a.k.a. Acceptance

Escalation to this level can happen when “you disagree with the Appeals Council decision, or you wish to escalate your appeal because the Appeals Council ruling timeframe passed.” At this level, win or lose, you should be prepared that this is the end of the line for the case you have been defending.

Resources:

Transmittal 543: Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R543PI.pdf

Link to OIG November 2012 Report – Improvements are Needed at the Administrative Law Judge Level of Medicare Appeals: http://oig.hhs.gov/oei/reports/oei-02-10-00340.pdf

Link to Statement of Nancy J. Griswold, Chief Administrative Law Judge to the United States House Committee on Oversight & Government Reform: http://oversight.house.gov/wp-content/uploads/2014/07/CMS-Griswold-OMHA-Final.pdf

Link to Medicare Learning Network’s Medicare Appeals Process Fact Sheet (ICN 006562 August 2014): http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareAppealsprocess.pdf

Link to Statistical Sampling Initiative: http://www.hhs.gov/omha/statistical_sampling_initiative.html

Link to Settlement Conference Facilitation Pilot: http://www.hhs.gov/omha/settlement_conference_facilitation_pilot.html

Medicare Appeals Settlement: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html

This is Respiratory Care Week and we at MMP would like to thank all of you who provide respiratory care for your hard work and dedication to improving the respiratory health of your patients. When my oldest son was eleven, he had severe pneumonia that required an extended hospitalization. I remember anxiously watching as the respiratory care team provided wonderful services that helped him to recover. Healthcare is most appreciated when truly needed and I am most appreciative of the care given by those respiratory therapists to my young son.

That son now has two beautiful children, the youngest a one-year old daughter. She now understands the word “no” but very much does not like to hear it. Like her, for all of us, it is sometimes hard to be told “no” constantly. Unfortunately, Medicare’s National Correct Coding Initiative (NCCI) often tells providers “no” about the reporting of certain code combinations. Respiratory services are no exception and in honor of Respiratory Care Week, I thought I would review some of the CCI edits for respiratory services. The complete CCI edits can be found at the Medicare NCCI webpage. The information below comes from the NCCI Policy Manual, Chapter 11. Please refer to this manual for more information.

• Alternate methods of reporting data obtained during a spirometry or other pulmonary function session should not be reported separately. For example, the flow volume loop is an alternative method of calculating a standard spirometric parameter. CPT code 94375 is included in standard spirometry (rest and exercise) studies.
• If multiple spirometric determinations are necessary to complete the service described by a CPT code, only one unit of service should be reported. For example, CPT code 94070 describes bronchospasm provocation with an administered agent and utilizes multiple spirometric determinations as in CPT code 94010. A single unit of service includes all the necessary spirometric determinations.
• Complex pulmonary stress testing (CPT code 94621) is a comprehensive stress test with a number of component tests separately defined in the CPT Manual. It is inappropriate to separately code venous access, ECG monitoring, spirometric parameters performed before, during and after exercise, oximetry, O2consumption, CO2production, rebreathing cardiac output calculations, etc., when performed as part of a complex pulmonary stress test.
• CPT code 94060 (bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) describes a diagnostic test that is utilized to assess patient symptoms that might be related to reversible airway obstruction. It does not describe treatment of acute airway obstruction. CPT code 94060 includes the administration of a bronchodilator. It is a misuse of CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) to report 94640 for the administration of the bronchodilator included in CPT code 94060. The bronchodilator medication may be reported separately.
• CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) and CPT code 94664 (demonstration and/or evaluation of patient utilization of an aerosol generator...) generally should not be reported for the same patient encounter. The demonstration and/or evaluation described by CPT code 94664 is included in CPT code 94640 if it utilizes the same device (e.g., aerosol generator) that is used in the performance of CPT code 94640. If performed at separate patient encounters on the same date of service, the two services may be reported separately.
• CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) describes either treatment of acute airway obstruction with inhaled medication or the use of an inhalation treatment to induce sputum for diagnostic purposes. CPT code 94640 should only be reported once during a single patient encounter regardless of the number of separate inhalation treatments that are administered. If CPT code 94640 is used for treatment of acute airway obstruction, spirometry measurements before and/or after the treatment(s) should not be reported separately. It is a misuse of CPT code 94060 to report it in addition to CPT code 94640. The inhaled medication may be reported separately.

There has been a lot of discussion about the last bullet point, which was new for 2014, that states that inhalation treatment “should only be reported once during a single patient encounter”. The issue is the definition of the term “encounter”. According to a statement issued by a coding specialist for NCCI, “encounter” in this instance means “direct personal contact in the hospital between a patient and a physician (or other clinician)… If the professional completes the inhalation service(s) and terminates the patient encounter but returns later that day to initiate additional inhalation treatment(s) reportable as CPT code 94640, an additional UOS (unit of service) of CPT code 94640 may be reported for this subsequent patient encounter.” We encourage all providers to clarify the interpretation of the term “encounter” with your Medicare Administrative Contractor (MAC) and other payers.

These NCCI rules again demonstrate that healthcare involves more than just providing patient care. Coding and billing play a major part in all aspects of healthcare. So someone in your Respiratory Care department needs to be aware of and understand the coding and billing requirements for Medicare and other payers. Because when Medicare says “no”, they mean “no”.

Medical Management Plus enjoys acknowledging the various healthcare professionals with whom we work during their designated annual recognition times. October is National Physical Therapy month and we thank all of those who work diligently in the physical therapy occupation to improve the health of their patients. In association with this recognition, here are some questions and answers related to Medicare therapy services.

1. If a patient in a hospital setting (observation or inpatient) receives therapy services, do you have to follow the Part B (general considered outpatient) therapy guidelines?
2. outpatients receiving observatipon services
3. inpatients whose inpatient admission does not meet criteria so only Part B services are billed, and
4. inpatients who only have Medicare Part B coverage (patient does not have Medicare Part A or Part A benefits are exhausted).
   The 2014 IPPS Final Rule states “we (CMS) believe we also must apply the therapy caps and all other Part B coverage and payment rules to hospital inpatient therapy services paid under Part B. Accordingly, (therapy services) billed to Medicare Part B, … will be subject to the Part B therapy caps …, the therapy caps exceptions process, the manual medical review process, and all other requirements for payment and coverage of therapy services under Part B (for example, functional status reporting requirements).”
5. Is a discharge summary required for all Medicare patients receiving outpatient therapy services?Yes, the Medicare Benefits Policy Manual, Chapter 15, Section 220.3 states:
   “The Discharge Note (or Discharge Summary) is required for each episode of outpatient treatment. … The discharge note shall be a progress report written by a clinician, and shall cover the reporting period from the last progress report to the date of discharge. In the case of a discharge unanticipated in the plan or previous progress report, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified personnel.”
6. If a patient discontinues outpatient therapy unexpectedly, must you report a discharge functional limitation HCPCS (G) code and modifier? What do you do if the same patient later returns to continue therapy?
   
   Per MLN Matters Special Article SE 1307: “Discharge reporting is required at the end of the reporting episode or to end reporting on one functional limitation prior to reporting on another medically necessary functional limitation. The exception is in cases where the beneficiary discontinues therapy expectantly. When the beneficiary discontinues therapy expectantly, we encourage clinicians to include discharge reporting whenever possible on the claim for the final services of the therapy episode.
   
   When a beneficiary discontinues therapy without notice, and returns less than 60 calendar days from the last recorded DOS to receive treatment for:
7. the same functional limitation, the clinician must resume reporting following the reporting requirements outlined in the “Required Reporting of Functional Codes” subsection; or
8. a different functional limitation, the clinician must discharge the functional limitation that was previously reported and begin reporting on a different functional limitation at the next treatment DOS.
9. NOTE: A reporting episode will automatically be discharged when it has been 60 or more calendar days since the last recorded DOS.
10. Is it appropriate to use modifier 59 to by-pass CCI edits for therapy services that are performed during the same session but at separate times?
11. Yes, per the NCCI manual, “Some NCCI edits pair a “timed” CPT code with another “timed” CPT code or a non-timed CPT code. These edits may be bypassed with modifier 59 if the two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter.”
12. Where can I find the information on the time reporting requirements for rehabilitative therapy services?
13. That information can be found in the,Medicare Claims Processing Manual, chapter 5 ,section 20.2and also -Medicare Therapy Billing Scenarios
14. Are Medicare contractors and affiliates still performing medical review of therapy services?
15. Yes, the RACs continue to perform manual medical review of therapy services exceeding the annual threshold amount and the OIG recently published areview of outpatient therapy services. Although this review focused on an independent therapy provider (not hospital outpatient), the findings are relevant to therapy in either setting. Findings included:
    
16. Plan of Care (POC) goals that were not measurable or pertinent to the patient’s functional limitation,
17. Problems with the therapist’s signature on the POC and treatment notes
18. Lack of specific skilled interventions in the treatment notes
19. Lack of documentation of time
20. Lack of medical necessity for therapy services
21. Progress notes not performed every 10th treatment day
22. Physician certifications not signed and/or dated
23. Other Medicare contractors such as the Medicare Administrative Contractors (MACs) and CERT reviewers may also review therapy records.

As always, therapists have more to worry about than just how their patients are progressing.

In this week’s article, we are featuring Neoplasms focusing mainly on the differences between ICD-9-CM and ICD-10-CM Coding Guidelines. There are only a few changes in the wording of the guidelines but there are several additional guidelines in ICD-10-CM. Only the differences in the two classification systems are listed below.

Unless otherwise indicated, these guidelines apply to all health care settings.‍

GUIDELINES COMPARISON

‍Primary malignant neoplasms overlapping site boundaries

A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 ('overlapping lesion'), unless the combination is specifically indexed elsewhere.

For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned.

Malignant neoplasm of ectopic tissue

Malignant neoplasms of ectopic tissue are to be coded to the site of origin mentioned, e.g., ectopic pancreatic malignant neoplasms involving the stomach are coded to pancreas, unspecified (C25.9).

The neoplasm table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate.

EXAMPLE

If the documentation indicates “adenoma,” refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to “see also neoplasm, by site, benign.” The table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the table that corresponds to the type of neoplasm. The Tabular List should then be referenced to verify that the correct code has been selected from the table and that a more specific site code does not exist.

See Section I.C.21. Factors influencing health status and contact with health services, Status, for information regarding Z15.0, codes for genetic susceptibility to cancer.

 ‍

GUIDELINES COMPARISON

‍Additional guidelines in ICD-10-CM

2.i) Malignancy in two or more noncontiguous sites

A patient may have more than one malignant tumor in the same organ. These tumors may represent different primaries or metastatic disease, depending the site. Should the documentation be unclear, the provider should be queried as to the status of each tumor so that the correct codes can be assigned.

2.j) Disseminated malignant neoplasm, unspecified

Code C80.0, Disseminated malignant neoplasm, unspecified, is for use only in those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified. It should not be used in place of assigning codes for the primary site and all known secondary sites.

2.k) Malignant neoplasm without specification of site

Code C80.1, Malignant (primary) neoplasm, unspecified, equates to Cancer, unspecified. This code should only be used when no determination can be made as to the primary site of a malignancy. This code should rarely be used in the inpatient setting.

2.l) Sequencing of neoplasm codes

2.l.1) Encounter for treatment of primary malignancy

If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the principal/first-listed diagnosis. The metastatic sites.

2.l.2) Encounter for treatment of secondary malignancy

When an encounter is for a primary malignancy with metastasis and treatment is directed toward the metastatic (secondary) site(s) only, the metastatic site(s) is designated as the principal/first-listed diagnosis. The primary malignancy is coded as an additional code.

2.l.3) Malignant neoplasm in a pregnant patient

When a pregnant woman has a malignant neoplasm, a code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, should be sequenced first, followed by the appropriate code from Chapter 2 to indicate the type of neoplasm.

2.l.4) Encounter for complication associated with a neoplasm

When an encounter is for management of a complication associated with a neoplasm, such as dehydration, and the treatment is only for the complication, the complication is coded first, followed by the appropriate code(s) for the neoplasm.

The exception to this guideline is anemia. When the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease.

2.l.5) Complication from surgical procedure for treatment of a neoplasm

When an encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of the neoplasm, designate the complication as the principal/first-listed diagnosis. See guideline regarding the coding of a current malignancy versus personal history to determine if the code for the neoplasm should also be assigned.

2.l.6) Pathologic fracture due to a neoplasm

When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, and followed by the code for the neoplasm.

If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture.

2.m. Current malignancy versus personal history of malignancy

When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.

When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

See Section I.C.21. Factors influencing health status and contact with health services, History (of)

2.n. Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms inremission versus personal history

The categories for leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved remission.

There are also codes Z85.6, Personal history of leukemia, and Z85.79, Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues.

If the documentation is unclear, as to whether the leukemia has achieved remission, the provider should be queried.

See Section I.C.21. Factors influencing health status and contact with health services, History (of)

2.o. Aftercare following surgery for neoplasm

See Section I.C.21. Factors influencing health status and contact with health services, Aftercare

2.p. Follow-up care for completed treatment of a malignancy

See Section I.C.21. Factors influencing health status and contact with health services, Follow-up

2.q. Prophylactic organ removal for prevention of malignancy

See Section I.C. 21, Factors influencing health status and contact with health services, Prophylactic organ removal

NOTE FROM AUTHOR

Notice the dashes (-) in the neoplasm table below:

Note: Codes listed with a dash (-), following the code, have a required additional character for laterality. The tabular must be reviewed for the complete code.

Example: Adrenal cortex (C74.0-) requires a fifth digit to determine right, left, or unspecified adrenal cortex for code completion.

If you haven’t done so already, MMP strongly encourages you to review all of the ICD-10-CM Coding Guidelines for each chapter. Often, we tend to use our memory when utilizing the guidelines and a refresher just might be helpful. You may be amazed at the guidelines that you remember and those you may have forgotten.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

Resources:

AHIMA ICD-10-CM Training Manual

ICD-10-CM Coding Book by Ingenix

The Fourth Time’s the Charm

CMS is having a hard time getting their transmittal concerning the denial of related claims correct. Perhaps the fourth time is the charm and hopefully between the writing of this article and its subsequent publication in our weekly newsletter, CMS will not rescind and republish this change request yet again. Originally back in February, CMS published Transmittal 505 but in a little over a month, it was rescinded due to the need to “clarify CMS policy.” Then on August 8th, Transmittal 534 was released – please refer to our article Medicare Allows Denials of Related Claims. This one lasted less than a month, and four days before the effective date it was replaced with Transmittal 540. I immediately recognized a discrepancy in Transmittal 540 between the policy section and the Manual Instructions. Evidently CMS also saw the error and hence the latest revision to these instructions in Transmittal 541.

So what has changed from version 1 to 2 to 3 to 4?

Version One (Transmittal 505) gave the MAC, RAC and ZPIC the discretion to deny a part B claim related to a denied part A claim which was not considered reasonable and necessary. It included an example of a diagnostic test deemed not reasonable and necessary, allowing the denial of the professional component for that test.

In Transmittal 534, the second version, the diagnostic test example was removed and the RACs must utilize the review approval process as outlined in their scope of work when performing reviews of “related” claims. This transmittal also required CMS approval before MACs and ZPICs can initiate “related” reviews and MACs must publish notice of such reviews on their website. The example given in this transmittal included denial of physician claims if a procedure was determined to not be medically necessary and downgrading the physician’s E&M service from inpatient to outpatient if the inpatient stay was determined to not meet criteria (that is, the services could have been provided on an outpatient basis).

Version Three, Transmittal 540, replaced 534 “to adhere to CMS Inpatient recoding policy standards” and the part of the above noted example related to down-coding physician E&M services from inpatient to outpatient was removed. The only example now listed is:

“When the Part A Inpatient surgical claim is denied as not reasonable and necessary, the MAC may recoup the surgeon's Part B services. For services where the patient’s history and physical (H&P), physician progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, postpayment recoupment may occur for the performing physician’s Part B service.”

Transmittal 540 corrected the above example in the Manual Instructions, but kept the “old” example in the policy section – likely an oversight. Transmittal 541, the fourth and hopefully final version, makes the example consistent in both sections.

So for now it appears the denial of related claims is limited to inpatient surgical claims where the surgical procedure itself is determined to not be medically necessary based on the documentation in the hospital record. This should be an impetus for both hospitals and physicians to make sure documentation in the hospital’s record supports the medical necessity of the procedure. This may require including documentation from the physician’s office records in the hospital medical record to provide sufficient history of the condition and previous treatments to justify the procedure. Though this step toward coordination of reviews between hospital and physician records has gotten smaller and smaller, at least it is a starting point. Maybe in the future CMS will expand its scope.

Q:
An article in a recent Wednesday@One talked about the medically unlikely edits (MUEs) and the newly published MUE Adjudication Indicators (MAIs). In the past, CMS did not publish all MUE values – some were maintained as confidential. Does the implementation of the MAIs mean that all MUE values are now published? 

A:

No, even with the implementation of MAIs, not all MUEs and their corresponding MAIs are published. This is explained best in Transmittal 1421. Below is the excerpt from Transmittal 1421. Transmittals are technical directions to the Medicare Administrative Contractors (MACs) so the organization referenced in the quote refers to the MACs.

“For HCPCS codes with confidential MUEs (i.e., Publication Indicator = 0), the MAI levels may not be published or shared with anyone outside of your organization. All other MAIs for non-confidential MUEs can be published or shared.”

What Is and What Is Not?

Since CMS guidance on the two-midnight benchmark and presumption was put forth in the 2014 IPPS Final Rule, CMS and their contractors have worked at educating providers on what appropriately constitutes a two-midnight expectation and how that needs to be documented in the medical record. The Medicare Administrative Contractors (MACs) are in the midst of the Probe and Educate program where they review short stay inpatient claims, make their determination regarding the appropriateness of inpatient status and then educate providers on their specific cases. So a lot is being said about “what is” an appropriate inpatient admission, but “what is not” an appropriate inpatient admission beyond the consideration of two midnights?

With the implementation of the two-midnight benchmark, CMS intended to reduce inappropriate payments for medically unnecessary short-stay inpatient admissions and to reduce extended observation stays. CMS has made it clear that if a patient receiving observation services is approaching a second midnight and will still be receiving medically necessary services requiring a hospital setting, then it is appropriate for the physician to order an inpatient admission. In our review of 835 claims data, Medical Management Plus is seeing some hospitals that continue to have a large percentage of their observation stays that go beyond the second midnight. These cases could potentially have been converted to an inpatient admission prior to the second midnight. We encourage all hospitals, but especially those hospitals with a high incidence of obs stays beyond a second night, to have systems in place that allow case managers to carefully evaluate observation stays approaching a second midnight to determine if they should be appropriately converted to an inpatient status. This would result in the hospital receiving an MS-DRG payment instead of an outpatient payment.

But don’t assume that just because the patient is there past a second midnight that an inpatient admission is always correct. With this in mind, is it ever appropriate to have an outpatient stay or outpatient with observation stay that goes beyond a second midnight? The answer is yes because not all patients staying for a second night are still receiving medically necessary therapeutic or diagnostic services that require a hospital setting. Medical Management Plus recently reviewed several outpatient records with a length of stay exceeding 24 hours and two midnights to determine if we thought an inpatient admission would have been appropriate.

We admit that although CMS has indicated they believe their current guidance is much easier to understand and implement, there is still a lot of subjective judgment in determining patient status. But here are some of the circumstances that we observed in our review that we believe do not warrant an inpatient admission:

• Patients who complete diagnostic testing prior to the second midnight but remain in the hospital a second night waiting on the attending physician to evaluate test results
• The patient’s treatment is not completed until late at night and the patient remains overnight due to the late hour to be discharged the next morning
• Needed tests or treatments are delayed because it is the weekend
• Lack of communication, timely orders, physician availability or other causes of delays in obtaining needed consultations
• Unable to discharge patient while making post-acute care discharge arrangements
• Outpatient testing that could have been safely provided on an outpatient basis after the patient was discharged, but is provided while the patient is in the hospital for patient convenience

There were also some records where the reason for the second midnight stay was not clearly documented. For example, if the patient is staying for tests that could be provided on an outpatient basis, is he/she staying because of physician concerns about the patient‘s risk? Is that last hemodialysis treatment in the hospital due to the patient’s medical condition or for the patient’s convenience? As always, clear and complete physician documentation is critical to knowing the correct patient status.

Part I can be found by clicking here.

Coding of Burns and Corrosions

There is now a distinction made in ICD-10-CM between burns and corrosions. Coding guidelines are the same for both burns and corrosions. The difference between the two would be:

• Burns – Thermal burns from a heat source.

1. Fire
2. Hot appliance
3. Electricity
4. Radiation
5. Sunburns are not included

• Corrosion – A burn secondary to chemicals (as it makes contact with external or internal tissue) such as:

1. Acids
2. Bases
3. Oxidizers
4. Solvents
5. Alkylants
6. Mustard gas

Current burns are classified in ICD-10-CM by:

• Body site
• Depth – Burns located at the same site but of different degrees is coded to the highest degree documented by provider
• First degree – erythema
• Second degree – blistering
• Third degree – full thickness injury
• Extent – Total Body Surface (TBS) for Third Degree Burns

1. Burns – Category T31
2. Corrosions – Category T32

• T31 and T32 are based on the classic “rule of nines” in estimating TBS

1. Head and neck – 9%
2. Each arm – 9%
3. Each leg – 18%
4. Anterior trunk – 18%
5. Posterior trunk – 18%
6. Genitalia – 1%

• Percentage assignment may be changed by providers to accommodate patients with larger heads, buttocks, thighs or abdomen
• Categories T30.0 and T30.4 for Burn or Corrosion of unspecified body region, unspecified degree are not to be assigned on inpatient accounts
• External cause / Agent
• Laterality
• Left
• Right
• Unspecified
• Encounter – Seventh character designates episode of care
• Initial encounter – A
• Subsequent encounter – D
• Sequela – S (encounters for late effects of burns or corrosions such as scars or joint contractures)

NOTE FROM ICD-10-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING

Section I.C.19.d.3

Non-healing burns are coded as acute burns.

Necrosis of burned skin should be coded as a non-healed burn.

Sequencing Burns / Corrosions

• Sequence code reflecting the highest degree first when more than one burn/corrosion is documented
• When both internal and external burns/corrosions have been documented, the circumstances of admission govern the selection of the principal diagnosis
• When the admission is for burn injuries and other related conditions such as respiratory failure and/or smoke inhalation, the circumstances of admission govern the selection of principal diagnosis

Adverse Effects, Poisoning, Under-dosing and Toxic Effects

Codes within the category T36 – T65 range are combination codes. This would include the substance related to the poisoning, adverse or toxic effect, under-dosing and the external source. There will be no need to assign an additional external cause code in ICD-10-CM.

Adverse Effect

An appropriate code should be assigned for Adverse Effect when the drug was correctly prescribed and administered. An additional code should be assigned to show the manifestation of the Adverse Effect. Examples would be:

• Tachycardia
• Delirium
• GI Bleeding
• Renal Failure
• Respiratory Failure
• Nausea and vomiting

Poisoning

A Poisoning would constitute a reaction to the improper use of a medication via:

• Intentional overdose
• Error made in drug prescription
• Interaction of drugs and alcohol
• Nonprescription drug taken with correctly prescribed and administered drug

Poisoning codes have an associated intent shown in the 5th or 6th character.

• Accidental
• Intentional self-harm
• Assault
• Undetermined

An additional code should be assigned for all manifestations associated with poisonings.

A code for abuse or dependence should also be assigned if the provider documents a diagnosis of abuse or dependence of a drug/substance.

Coders should assign as many codes necessary to fully describe all drugs/substances and manifestations described for a particular admission.

Under-dosing

Under-dosing is a new concept under ICD-10-CM and is defined as taking less of a drug than is recommended or prescribed by a provider or the manufacturer.

• A code for under-dosing should never be assigned as a principal diagnosis.
• Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) code is to be used with an under-dosing code to indicate intent, if known.